36C25018Q0797-003.docx

PAST PERFORMANCE QUESTIONNAIRE

REQUEST FOR QUOTATION (RFQ) 36C25018Q0611

RRESIDENTIAL SUBSTANCE ABUSE SERVICES

ANN ARBOR VA Medical Center

MESSAGE TO THE EVALUATOR: Your assistance is requested by Robert kay, Contracting Officer to assist with establishing the performance history for the Company (Quoter) named below. In efforts to expedite receipt of the requested information, the Contracting Office respectfully requests that you do not mail hard copies. Instead, please e-mail the completed past performance questionnaire(s) to: robert.kay@va.gov. If enough space is not provided, then please attach additional information to this questionnaire. Please provide the survey back on or before the time and date listed in block 8.

1. Name of Offeror /Agency:

Contract Number:

Title/Description of Contract:

Period of Performance:

Based upon the definitions below, indicate your assessment of the offeror’s performance. Your assessment should consider the offeror’s performance in accordance with the contractual requirements. Please include the period of performance and contract value:

2. Brief description of scope of work:

EVALUATION: Please rate the offeror using the guide and the pull-down menus in the evaluation table below. Explanatory narratives for as many responses as possible would be appreciated. These narratives need not be lengthy, just detailed. Attach additional pages if more space is needed.

Would you award similar contracts to this offeror? Please provide explanation for response.

EXPLANATION OF OVERALL RATING GIVEN:

ADDITIONAL COMMENTS (use additional pages as required)

ASSESSOR NAME AND INFORMATION

Name & Signature of Assessor’s:

Company/Agency: Date:

Position Title/Grade: Contracting Officer Phone:

Email: Fax:

ATTACHMENT 3 - CONTRACTORS COMPLIANCE WITH IMMIGRATION

CONTRACTOR CERTIFICATION OF COMPLIANCE WITH THE IMMIGRATION AND NATIONALITY ACT OF 1952.

1. The Contractor certifies that the Contractor shall comply with any and all legal provisions contained in the Immigration and Nationality Act of 1952, As Amended; its related laws and regulations that are enforced by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor as these may relate to non-immigrant foreign nationals working under contract or subcontract for the Contractor while providing services to Department of Veterans Affairs patient referrals.

2. While performing services for the Department of Veterans Affairs, the Contractor shall not knowingly employ, contract or subcontract with an illegal alien; foreign national non-immigrant who is in violation their status, as a result of their failure to maintain or comply with the terms and conditions of their admission into the United States. Additionally, the Contractor is required to comply with all “E-Verify” requirements consistent with “Executive Order 12989” and any related pertinent Amendments, as well as applicable Federal Acquisition Regulations.

3. If the Contractor fails to comply with any requirements outlined in the preceding paragraphs or its Agency regulations, the Department of Veterans Affairs may, at its discretion, require that the foreign national who failed to maintain their legal status in the United States or otherwise failed to comply with the requirements of the laws administered by Homeland Security, Immigration and Customs Enforcement and the U.S Department of Labor, shall be prohibited from working at the Contractor’s place of business that services Department of Veterans Affairs patient referrals; or other place where the contractor provides services to veterans who have been referred by the Department of Veterans Affairs; and shall form the basis for termination of this contract for breach.

4. The Contractor agrees to obtain a similar certification from its subcontractors.

Signature: _____________________________________________ Date: _________________________________________________ Typed Name and Title: ___________________________________ Company Name: ________________________________________

5. This certification concerns a matter within the jurisdiction of an agency of the United States and the making of a false, fictitious or fraudulent certification may render the maker subject to prosecution under 18 U.S.C. 1001.

ATTACHMENT 4 - QUALITY ASSURANCE SURVEILLANCE PLAN